A teenage girl sent to a mental health unit 80 miles away took her own life five days after she was discharged back to her home in Bristol.

Becky Romero, aged 15, was sent home from the unit in Bournemouth, Dorset, after less than a month, but there was no bed in the only equivalent unit in Bristol, and within a week she had taken her own life at the family home in Bedminster Down.

An inquest has heard of a catalogue of failings and problems which meant she fell through the gaps of care – from the lack of a robust care plan back in Bristol, to the decision to discharge her from the unit in Bournemouth being taken by a student nurse.

During emotional scenes at Avon Coroners’ Court, Becky’s parents Nicola and Tony questioned mental health workers who dealt with Becky both here and in Bournemouth, but then embraced them after questioning ended.

UPDATE:

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The 15-year-old’s case is already understood to have led to a call for changes at NHS England, which manages adolescent mental health care, because doctors at the Riverside said they could not even offer Becky a place in its day care service.

The inquest heard Becky had struggled with mental health after being bullied at her junior school and again at Bedminster Down School.

Becky Romero, from South Bristol, who died in July 2017

She was home-schooled and then a place was found for her at a hospital school, but her mum told the inquest she effectively had not left her home for two years.

After several attempts to take her own life, which climaxed in one serious attempt in early June this year, and regular self-harming she was admitted to Bristol Royal Children’s Hospital, and a place was quickly found for her at the nearest adolescent mental health unit, Pebble Lodge in Bournemouth.

The inquest was told the 15-year-old was obsessed with using her smart phone to talk to friends in America she’d met online. Her obsession reached the point where she would sleep all day to be up during the night to talk with them, because of the time difference in the US.

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She began a relationship with one 16-year-old girl, Auri, but when that relationship broke down, she spiralled further into self-harm and attempts to take her own life.

The inquest heard from Sarah Shapter who, at the time, was a student nurse and Becky’s one-to-one key worker at Pebble Lodge.

She said Becky had made progress, coming out of her shell to talk more about her feelings, and had not appeared to have self-harmed.

Pebble Lodge in Bournemouth

Access to her phone was restricted in Pebble Lodge, but Ms Shapter said that because she was a patient from ‘out of the area’, more formal psychology and psychiatry work had not begun with her, because managers did not want to start that work and then have Becky moved back to Bristol when a bed at Riverside became available.

On July 6, less than four weeks after she was admitted because of a suicide attempt, Becky was told she was going on weekend leave, but then at the last minute told it might be extended, so she had to take all her belongings.

Her emotional father Tony, 47, said Becky was crying and did not want to leave Pebble Lodge, but was made to put all her belongings into black bin liners.

The decision to formally discharge her was taken after a student nurse, Sarah Shapter, spoke to her mum Nicola over the phone.

“Becky was too upset to talk, she was crying as she was desperate to go back,” Mrs Romero told the inquest. “I was trying to tell them that Pebble Lodge was the only place Becky felt safe. We were so confused about why she was not allowed to go back.”

Ms Shapter said the idea was to allow Becky to go home for a visit on leave, and if that went well, then to discharge her.

Her father Tony said: “We thought we had finally got Becky somewhere where she would be treated and looked after.

“When I went to pick her up for the weekend leave, I thought she was only coming home for the weekend. So did Becky, and then they called her back as she was walking out to my car and said ‘no you’ve got to take all your stuff’,” he added.

But back in Bristol, there were problems with the care package set up for Becky.

After she was admitted to Pebble Lodge, she was assigned a care co-ordinator, clinical psychologist Dr Ellie Cullum, who works for South Bristol CAMHS (Children and Adolescent Mental Health Services).

Dr Cullum had treated Becky a year earlier during a previous deterioration in her mental health, but had not seen her since.

She told the inquest that she and other members of the team in Bristol had discussed with their colleagues in Bournemouth the possibility of detaining Becky under the Mental Health Act if she attempted to leave Pebble Lodge, as she arrived.

Friends of Becky Romero gather to release balloons at a vigil for her in Highridge

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Dr Cullum told the inquest that she tried to put together a care package for Becky in Bristol. “Becky wanted to come home, or be nearer her family, obviously,” she said. “She didn’t like being so far away from home.”

“We inquired whether a bed might become available at Riverside so she could transfer directly to there, or whether a day bed was available so that she could go there during the day and sleep at home at night, but none of that was available,” she added.

“We tried to put the best contingency plan we could in place with the resources available. A community CAMHS support can’t have more than once a week contact, which is quite a change from 24-7 coverage. I discussed with the community CAMHS team about a more intensive package, where we pooled different services,” she added.

But part of that extra help was the hospital school service, which broke up in the middle of July, something Dr Cullum said she was not aware of.

They agreed to let her leave – even though there were no beds available at the only equivalent unit in Bristol.

Mental health workers working in south Bristol tried to put in place an enhanced care package, but within days she had taken her own life at her home in Bedminster Down.

An inquest heard the 15-year-old’s care co-ordinator told staff at Pebble Lodge, the care unit in Bournemouth where Becky had been sent to following several suicide attempts, that there was no beds available – even just as a day patient – at the Riverside, Bristol’s only adolescent mental health unit.

At a tense hearing at Avon Coroner’s Court, Becky’s devastated parents asked her care-co-ordinator at the South Bristol CAMHS (Children and Adolescent Mental Health Service) why she was allowed to leave Pebble Lodge, which was 80 miles away in Bournemouth, but clinical psychologist Ellie Cullum said she didn’t know.

A catalogue of failings are emerging at Becky’s inquest, which is scheduled to take two days and hear from a series of mental health workers both in Bristol and Bournemouth, about her care in the days and weeks leading up to her death in July this year.

The 15-year-old suffered from a range of mental health issues, including depression, severe anxiety and feelings of self-harm and suicide for several years before her death.

She had attempted to take her own life in June, and was admitted initially to Bristol Children’s Hospital, and was quickly found a bed at the nearest mental health unit – Pebble Lodge, in Bournemouth on June 10.

Coroner Maria Voisin heard that she made progress at Pebble Lodge over the next few weeks, and went on a period of leave back to her home in Bedminster Down on July 6.

However, after a few days of staying with her family, Pebble Lodge told her mum Nicola that she was being discharged because she had got on well at home.

The inquest continues and is expected to take two days.

Most people who are thinking of taking their own life have shown warning signs beforehand.

These can include becoming depressed, showing sudden changes in behaviour, talking about wanting to die and feelings of hopelessness.

These feelings do improve and can be treated. If you are concerned about someone, or need help yourself, please contact the Samaritans on 116 123.